Gastroenterology
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| What is the most common cause of lower GI bleeding | Hemorrhoids
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| Common, painless and can be massive, caused from an erosion into penetrating artery from the diverticulum | Diverticulosis
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| What is the most common cause of upper GI bleed | Peptic ulcer disease
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| Cause of esophageal and gastric varices | Portal hypertension
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| Longitudinal mucosal tear in the cardioesophageal region, caused by repeated retching | Mallory-Weiss syndrome
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| Common cause of lower GI bleeding, seen in people with hypertension and aortic stenosis | Arteriovenous malformations
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| Spider angiomata, palmer erythema, jaundice, and gynecomastia are seen in __ | Liver disease
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| Petechiae and purpura seen in __ | Coagulopathy
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| Why would you do a careful ENT exam on a patient suspected of GI bleed | Rule out causes that can mimic GI bleed such as epistaxis
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| Can be diagnostic and therapeutic but requires a brisk bleed at .5-2ml/min | angiography
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| Can only be diagnostic but are more sensitive than angiography and require a bleeding rate of only .1ml/min | bleeding scans
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| Is diagnostic and therapeutic and more accurate than bleeding scans and angiography | Colonoscopy
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| For Class __ bleed: replace volume with crystalloid | I and II
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| For Class __ bleed: replace volume with crystalloid and blood | III and IV
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| Hemorrhaging is broken down into how many categories by the ACS | 4
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| Class __ hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs and fluid resuscitation is not usually necessary | I
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| Class _ hemorrhage involves 15-30% of total blood volume. A patient is often tachy, narrowed pulse pressure. Peripheral vasoconstriction, pale cool skin, slight changes in behavior, volume resuscitation with crystalloids | II
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| Class __ hemorrhage involves loss of 30-40% of blood volume; pt’s BP drops, HR increases, peripheral perfusion decreases (prolonged cap refill), mental status worsens; crystalloid & blood transfusions usually necessary | III
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| Class __ hemorrhage involves loss of >40% of blood volume; limit of body’s compensation is reached and aggressive resuscitation is required to prevent death | IV
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| __ ulcers do not extend through the muscularis mucosa | Stress
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| Only __ % of patients who are infected with H. pylori will develop ulcers | 10-20
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| Inhibits bicarbonate ion production and increases gastric emptying | Cigarette smoking
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| Main complaint of gastric ulcer | Gnawing, aching or burning epigastric pain
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| Physical exam of uncomplicated PUD, there may be a finding of __ | Epigastric tenderness
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| Inhibit gastric acid secretion, equally as effective as antacids with better compliance due to decreased frequency of doses | H2 antagonists
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| Inhibits gastric acid secretions, heals ulcers faster than H2-antagonists and antacids | PPI
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| Locally binds to the base of the ulcer and therefore protects it from acid | Sucralfate
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| Prostaglandin E1 analogue which acts as natural prostaglandin in the body | Misoprostol
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| Vomiting and diarrhea is most often __ | Gastroenteritis
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| Which is more common: upper or lower GI bleeding? | upper
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| What is the most common cause of acute lower GI bleeding? | hemorrhoids, followed by diverticular disease (most common cause of Acute GIB)
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| what is the most important lab test for a patient with a significant GI bleed | type and crossmatch
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| when is surgical treatment for hemorrhoids indicated | severe, intractable pain, continued bleeding, incarceration, or strangulation
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| treatment of choice for patients with pseudomembranous colitis | metronidazole for mild to moderate disease in patients who do not respond to supportive measures
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| __ should be reserved for patients with pseudomembranous colitis who have not responded to or are intolerant of metronidazole and for children and pregnant patients | vancomycin
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| for patients with pseudomembranous colitis __ may prolong or worsen symptoms and should be avoided | antidiarrheal agents
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| Meckler triad | Sx of esophageal perf: vomiting, chest pain, subQ emphysema
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| Upper vs lower GI bleed: anatomy | ligament of Treitz
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| Meds assoc w/GI bleed | NSAIDs; Steroids (in setting of NSAID); Warfarin; Heparin, Enoxaparin; Clopidogrel (Plavix)
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| 3 most common causes of upper GI bleed | PUD (55%); Varices (14%); AVM (6%)
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| 3 most common causes of lower GI bleed | Diverticular Dz (33%); Neoplastic Dz (Polyps, Ca; 19%); Colitis (18%)
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| Resting Tachycardia: blood loss = | 10% of intravascular volume lost
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| Orthostasis: blood loss = | Significant loss, 10-20% of intravascular volume
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| Shock: blood loss = | Loss of 20-40% of intravascular volume
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| Chronic GI blood loss: defined by: | Fe def anemia: Low Ferritin (<30); Low Fe, High TIBC; Low MCV; also Anemia w/brown stool (Guaiac pos)
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| GI bleed: mainstay of initial tx | Resuscitation; goal = normal vital sx; 2 lg bore IVs; ICU monitoring if needed
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| Dieulafoy’s Lesion = | Dilated submucosal artery erodes into mucosa with subsequent rupture of the vessel; bleeding often massive & recurrent
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| Mallory-Weiss tear: | Laceration in the mucosa, usually near GE junction; commonly after retching
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| Diagnostic tools for LGIB | Anoscopy; Flexible Sigmoidoscopy; Colonoscopy; Tagged red blood cell scan; Angiography
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| Diverticular bleeding: sxs and location | Acute, painless hematochezia; most bleeds are right sided
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| Role of tagged scan | help localize bleeding; pre-test for angiography; detects bleeding (0.1 to 0.5 mL/min; less sensitive w/inc bowel motility); no tx capability
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| LGIB: Angiography: caution: | Caution w/renal failure given IV contrast load
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| LGIB: Angiography: utility | Coil microembolization of bleeding vessel; blood flow must be 1 mL/min
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| Diverticular disease etiology | Herniations of colonic mucosa thru muscularis (typically at site of least resistance), often where nutrient artery penetrates muscularis; mostly in sigmoid (1/3 in proximal colon)
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| Contraindicated during acute diverticulitis: | colonoscopy / sigmoidoscopy
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| Diverticular disease imaging: | Xray (free abd air); CT (to dx abscess / inflammation); scopy to r/o or confirm dx; hemorrhage: 99mTc-labeled RBC scan, mesenteric angiogram, scintigraphy
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| Diverticular disease tx: | mild: PO Flagyl + (Cipro or SMX-TMP); hospitalize if no response to tx -> IV Abx
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| Causes of upper GI bleed | PUD, MW tear, AVM, esophageal varices
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| Meds assoc w/GI bleed | NSAIDs; Steroids (in setting of NSAID); Warfarin; Heparin, Enoxaparin; Clopidogrel (Plavix
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| 3 most common causes of upper GI bleed | PUD (55%); Varices (14%); AVM (6%)
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| 3 most common causes of lower GI bleed | Diverticular Dz (33%); Neoplastic Dz (Polyps, Ca; 19%); Colitis (18%)
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| Dieulafoy Lesion = | Dilated submucosal artery erodes into mucosa with subsequent rupture of the vessel; bleeding often massive & recurrent
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| Diverticular bleeding = | Acute, painless hematochezia; most bleeds are right sided
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| Definition and MOA of diverticulosis | herniation of mucosa through the muscular wall of the intestine
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| Most common cause of massive lower GI bleed in elderly: | diverticular bleeding
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| Orthostasis (SBP drops >10 and HR increases by 10 w/change in position) equates to what volume of blood loss in GIB? | 800 mL
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| GI bleed diagnostic algorithm | Stabilize VS (eg, fluid resuscitation, 20 ga IV x2); determine upper vs lower; scope +/- NGT for blood; ID source and tx
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| If EGD & colonoscopy are neg, consider: | small bowel studies (eg, VCE, SBFT)
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| If LGIB too brisk to allow colonoscopy, do: | 99mTc-labeled RBC scan, scintigraphy
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| Common cause of obscure bleeding (eg, in small bowel): | vascular ectasias (flat lesion, hard to visualize)
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